Comprehensive Dual Preferred Drug List (List of Covered Drugs)

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1 2015 Comprehensive Dual Preferred Drug List (List of Covered Drugs) Medicare Advantage Plans WellCare Florida Liberty (HMO SNP) Please Read: This document contains information about the drugs we cover in this plan. You are covered by both Medicare and Medicaid and you have chosen to get your Medicare prescription drug coverage and some Medicaid health care through our plan, WellCare Florida Liberty (HMO SNP). In addition to the items covered by your Medicare Part B and Part D benefit, the WellCare Florida Liberty (HMO SNP) plan also pays for some of your Medicaid-covered products, including some cough and cold medications, prescription vitamin and mineral products, and over-the-counter (OTC) drugs. All items covered on our plan require a prescription so that you are able to get them at your pharmacy. For additional information about this WellCare Florida Liberty (HMO SNP) plan, please visit our website at or call Customer Service at (TTY ). We are here for you Monday-Sunday, 8 a.m. to 8 p.m. FL027745_WCM_FOR_ENG W ellcare 2014 FL_09_14 FL5LIBFOR62642E 0914

2 Florida Liberty Cough and Cold Drug List PLEASE NOTE: The preferred cough & cold drugs on this list are covered only for members 20 years old or younger. Benzonatate BENZONATATE 100 MG CAPSULE BENZONATATE 200 MG CAPSULE Dextromethorphan Polistirex DELSYM 30 MG/5 ML EXTENDED-RELEASE SUSPENSION Dextromethorphan HBr ROBITUSSIN PEDIATRIC COUGH SYP Dextromethorphan HBr/Menthol DELSYM COUGH RELIEF PLUS LOZENGE Brompheniramine/Dextromethorphan HBr/Pseudoephedrine HCl BROTAPP DM LIQUID Q-TAPP DM ELIXIR Brophenaramine/Dextromethorphan HBr/Phenylephrine HCl RYNEX DM DIMAPHEN DM ELIXIR COLD/COUGH CHILDRENS ELIXIR Chlorpheniramine/Dextromethorphan HBr/Phenylephrine HCl CORFEN DM TRI-DEX PE DE-CHLOR DM LIQUID NOHIST-DM Chlorpheniramine/Dextromethorphan HBr/Pseudoephedrine HCl KIDKARE COUGH/COLD MESEHIST DM PEDIATRIC COUGH- COLD LIQUID Dexchlorpheniramine/Pseudoephedrine HCl/Chlophedianol HCl VANACOF LIQUID Chlorpheniramine/Dextromethorphan HBr DIMETAPP LONG-ACTING COUGH LIQ ROBITUSSIN LONG ACTING LIQUID Promethazine HCl/Dextromethorphan HBr PROMETHAZINE-DM SYRUP Dextromethorphan HBr/Acetaminophen/Doxylamine DELSYM NIGHTTIME MULTI-SYMPTOM Guaifenesin/Phenylephrine HCl DESPEC LIQUID RESCON-GG LIQUID Guaifenesin/Dextromethorphan HBr/Phenylephreine ROBAFEN CF SYRUP Dextromethorphan HBr/Guaifenesin MUCUS RELIEF COUGH LIQUID DIABETIC TUSSIN DM LIQUID GUAIFENESIN DM SYRUP Q-TUSSIN-DM SYRUP EXTRA ACTION COUGH SILTUSSIN DM COUGH SYRUP REFENESEN DM SILTUSSIN DM DAS COUGH SYRUP MUCOSA DM ROBITUSSIN COUGH CHEST CONGESTION DM LIQUID Last Updated 07/2014

3 Chlorpheniramine/Hydrocodone Polistirex TUSSICAPS (min. age 6 years old) HYDROCODONE-CHLORPHENIRAMINE SUSPENSION (min. age 6 years old) Codeine Phosphate/Promethazine HCl PROMETHAZINE-CODEINE SYRUP (min. age 6 years old) Codeine/Phenylephrine HCl/Promethazine PROMETH VC W/COD SYRUP PROMETHAZINE VC/COD SYRUP Pseudoephedrine HCl/Codeine/Chlorpheniramine PHENYLHISTINE DH Hydrocodone Bit/Homatropine HYDROCODONE-HOMATROPINE Codeine Phosphate/Guaifenesin GUAIFENESIN- IOPHEN C-NR CHERATUSSIN AC CODEINE SYRUP SYRUP Codeine Phosphate/Guaifenesin/Pseudoephedrine HCl CHERATUSSIN DAC SYRUP Last Updated 07/2014

4 *Alternative Medicines* *Alternative Medicine - M's**-*Alternative Medicine - Me's*** melatonin maximum strength oral tablet 5 mg P OTC *Analgesics - Anti-Inflammatory* *Nonsteroidal Anti-Inflammatory Agents (Nsaids)**-*Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** ibuprofen oral suspension 100 mg/5ml P OTC ibuprofen oral tablet 200 mg P OTC *Analgesics - Nonnarcotic* *Analgesics Other**-*Analgesics Other*** acetaminophen oral solution 160 mg/5ml P OTC acetaminophen oral tablet 325 mg P OTC; QL (279 EA per 31 days) acetaminophen oral tablet 500 mg P OTC; QL (186 EA per 31 days) apap oral tablet 325 mg P OTC; QL (279 EA per 31 days) apap extra strength oral tablet 500 mg P OTC; QL (186 EA per 31 days) childrens non-asa pain relief oral tablet chewable 80 mg P OTC childrens non-aspirin oral tablet chewable 80 mg P OTC childrens non-aspirin pain oral tablet chewable 80 mg P OTC childrens pain reliever oral tablet chewable 80 mg P OTC childrens silapap oral liquid 160 mg/5ml P OTC childrens tactinal oral tablet chewable 80 mg P OTC ed-apap oral liquid 160 mg/5ml P OTC mapap oral capsule 500 mg P OTC; QL (186 EA per 31 days) mapap oral tablet 325 mg P OTC; QL (279 EA per 31 days) mapap oral tablet 500 mg P OTC; QL (186 EA per 31 days) mapap oral tablet chewable 80 mg P OTC mapap arthritis pain oral tablet extendedrelease* 650 mg P OTC; QL (93 EA per 31 days) maxapap maximum strength oral tablet 500 mg P OTC; QL (186 EA per 31 days) maxapap regular strength oral tablet 325 mg P OTC; QL (279 EA per 31 days) non-aspirin oral tablet 325 mg P OTC; QL (279 EA per 31 days) non-aspirin extra strength oral tablet 500 mg P OTC; QL (186 EA per 31 days) non-aspirin pain relief oral tablet 325 mg P OTC; QL (279 EA per 31 days) 1

5 nortemp infants oral suspension 80 mg/0.8ml P OTC pain & fever childrens oral solution 160 mg/5ml P OTC pain relief oral tablet 500 mg P OTC; QL (186 EA per 31 days) pain relief extra strength oral tablet 500 mg P OTC; QL (186 EA per 31 days) PHARBETOL ORAL TABLET 325 MG P OTC; QL (279 EA per 31 days) PHARBETOL EXTRA STRENGTH ORAL TABLET 500 MG P OTC; QL (186 EA per 31 days) q-pap oral tablet 325 mg P OTC; QL (279 EA per 31 days) tactinal oral tablet 325 mg P OTC; QL (279 EA per 31 days) tactinal extra strength oral tablet 500 mg P OTC; QL (186 EA per 31 days) *Salicylates**-*Salicylate Combinations*** tri-buffered aspirin oral tablet 325 mg P OTC *Salicylates**-*Salicylates*** aspirin oral tablet 325 mg, 81 mg P OTC aspirin oral tablet chewable 81 mg P OTC aspirin oral tablet delayed release 81 mg P OTC aspirin adult low strength oral tablet delayed release 81 mg P OTC aspirin childrens oral tablet chewable 81 mg P OTC aspirin ec oral tablet delayed release 325 mg, 81 mg P OTC aspirin ec low dose oral tablet delayed release 81 mg P OTC aspirin low dose oral tablet 81 mg P OTC ECPIRIN ORAL TABLET DELAYED RELEASE 325 MG P OTC *Antacids* *Antacid Combinations**-*Antacid & Simethicone*** alamag plus oral tablet chewable mg P OTC ALMACONE ORAL SUSPENSION MG/5ML P OTC antacid oral suspension mg/5ml P OTC antacid anti-gas oral suspension mg/5ml P OTC antacid anti-gas max strength oral suspension mg/5ml P OTC antacid extra strength oral suspension mg/5ml P OTC antacid i oral suspension mg/5ml P OTC antacid iii oral suspension mg/5ml P OTC geri-lanta oral suspension mg/5ml P OTC MAALOX ADVANCED ORAL SUSPENSION MG/5ML P OTC 2

6 MAALOX ADVANCED MAX ST ORAL SUSPENSION MG/5ML P OTC MAALOX MAX ORAL SUSPENSION MG/5ML P OTC MAALOX MULTI SYMPTOM MAX ST ORAL SUSPENSION MG/5ML P OTC MAALOX REGULAR STRENGTH ORAL SUSPENSION MG/5ML P OTC milantex oral suspension mg/5ml P OTC milantex extra strength oral suspension mg/5ml P OTC MINTOX PLUS ORAL TABLET CHEWABLE MG P OTC *Antacid Combinations**-*Antacid Combinations*** ACID GONE ORAL TABLET CHEWABLE MG, MG P OTC MI-ACID ORAL TABLET CHEWABLE MG P OTC *Antacids - Aluminum Salts**-*Antacids - Aluminum Salts*** aluminum hydroxide gel oral suspension 320 mg/5ml P OTC *Antacids - Bicarbonate**-*Antacids - Bicarbonate*** sodium bicarbonate oral tablet 325 mg, 650 mg P OTC *Antacids - Calcium Salts**-*Antacids - Calcium Salts*** alcalak oral tablet chewable 420 mg P OTC antacid oral tablet chewable 420 mg, 500 mg P OTC CAL-GEST ANTACID ORAL TABLET CHEWABLE 500 MG P OTC calcium antacid oral tablet chewable 500 mg P OTC calcium antacid extra strength oral tablet chewable 750 mg P OTC calcium carbonate antacid oral tablet 648 mg P OTC calcium carbonate antacid oral tablet chewable 500 mg P OTC MAALOX ORAL TABLET CHEWABLE 600 MG P OTC TITRALAC ORAL TABLET CHEWABLE 420 MG P OTC *Antacids - Magnesium Salts**-*Antacids - Magnesium Salts*** magnesium oxide oral tablet 400 mg P OTC *Antidiabetics* *Diabetic Other**-*Diabetic Other*** BD GLUCOSE ORAL TABLET CHEWABLE 5 GM P OTC glucose oral tablet chewable 4 gm P OTC 3

7 ultilet glucose oral tablet chewable 4 gm P OTC *Antidiarrheals* *Antidiarrheal Agents - Misc.**-*Antidiarrheal Agents - Misc.*** bismatrol oral suspension 262 mg/15ml P OTC bismatrol oral tablet chewable 262 mg P OTC bismuth oral tablet chewable 262 mg P OTC diotame oral tablet chewable 262 mg P OTC kao-tin oral suspension 262 mg/15ml P OTC KAOPECTATE ORAL SUSPENSION 262 MG/15ML P OTC KAOPECTATE EXTRA STRENGTH ORAL SUSPENSION 525 MG/15ML P OTC pink bismuth oral suspension 262 mg/15ml P OTC pink bismuth oral tablet chewable 262 mg P OTC stomach relief oral suspension 262 mg/15ml, 527 mg/30ml P OTC stomach relief oral tablet chewable 262 mg P OTC stomach relief plus oral suspension 525 mg/15ml P OTC *Antiperistaltic Agents**-*Antiperistaltic Agents*** anti-diarrheal oral liquid 1 mg/5ml P OTC LOPERAMIDE A-D ORAL TABLET 2 MG P OTC loperamide hcl oral liquid 1 mg/5ml P OTC *Antidotes* *Antidotes**-*Antidotes*** ipecac oral syrup P OTC *Antiemetics* *Antiemetics - Anticholinergic**-*Antiemetics - Anticholinergic*** meclizine hcl oral tablet 12.5 mg, 25 mg P OTC *Antihistamines* *Antihistamines - Alkylamines**-*Antihistamines - Alkylamines*** aller-chlor oral syrup 2 mg/5ml P OTC aller-chlor oral tablet 4 mg P OTC allergy oral tablet 4 mg P OTC 4

8 allergy relief oral tablet 4 mg P OTC chlorhist oral tablet 4 mg P OTC chlorphen oral tablet 4 mg P OTC DIABETIC TUSSIN ALLERGY ORAL SYRUP 2 MG/5ML P OTC *Antihistamines - Ethanolamines**-*Antihistamines - Ethanolamines*** aler-cap oral capsule 25 mg P OTC aler-dryl oral tablet 50 mg P OTC alertab oral tablet 25 mg P OTC allergy relief childrens oral liquid 12.5 mg/5ml P OTC altaryl oral elixir 12.5 mg/5ml P OTC altaryl oral syrup 12.5 mg/5ml P OTC anti-hist oral capsule 25 mg P OTC anti-hist allergy oral tablet 25 mg P OTC BANOPHEN ORAL CAPSULE 25 MG P OTC BANOPHEN ORAL LIQUID 12.5 MG/5ML P OTC BANOPHEN ORAL TABLET 25 MG P OTC BENADRYL ALLERGY CHILDRENS ORAL LIQUID 12.5 MG/5ML P OTC complete allergy medication oral tablet 25 mg P OTC complete allergy relief oral tablet 25 mg P OTC diphenhist oral capsule 25 mg P OTC diphenhist oral liquid 12.5 mg/5ml P OTC diphenhist oral tablet 25 mg P OTC diphenhydramine hcl oral capsule 25 mg, 50 mg P OTC diphenhydramine hcl oral tablet 25 mg P OTC DORMIN ORAL CAPSULE 25 MG P OTC genahist oral capsule 25 mg P OTC pharbedryl oral capsule 25 mg, 50 mg P OTC q-dryl oral capsule 25 mg P OTC q-dryl oral liquid 12.5 mg/5ml P OTC quenalin oral syrup 12.5 mg/5ml P OTC SCOT-TUSSIN ALLERGY RELIEF ORAL LIQUID 12.5 MG/5ML P OTC siladryl allergy oral liquid 12.5 mg/5ml P OTC silphen cough oral syrup 12.5 mg/5ml P OTC 5

9 SIMPLY ALLERGY ORAL TABLET 25 MG P OTC total allergy oral tablet 25 mg P OTC TOTAL ALLERGY MEDICINE ORAL LIQUID 12.5 MG/5ML P OTC *Antihistamines - Non-Sedating**-*Antihistamines - Non-Sedating*** cetirizine hcl oral tablet 10 mg, 5 mg P OTC cetirizine hcl childrens oral solution 1 mg/ml P OTC cetirizine hcl childrens alrgy oral syrup 1 mg/ml P OTC loratadine oral tablet 10 mg P OTC loratadine hives relief oral solution 5 mg/5ml P OTC; QL (300 ML per 31 days) *Antiseptics & Disinfectants* *Iodine Antiseptics**-*Iodine Antiseptics*** OPERAND POVIDONE-IODINE EXTERNAL SOLUTION 10 % P OTC povidone-iodine external solution 10 % P OTC *Cough/Cold/Allergy* *Cough/Cold/Allergy Combinations**-*Decongestant & Antihistamine*** BROTAPP ORAL LIQUID 1-15 MG/5ML P OTC; AL (Max 20 Years) Q-TAPP ORAL ELIXIR 1-15 MG/5ML P OTC; AL (Max 20 Years) *Expectorants**-*Expectorants*** mucus relief oral tablet 400 mg P OTC refenesen oral tablet 200 mg P OTC refenesen 400 oral tablet 400 mg P OTC robafen oral syrup 100 mg/5ml P OTC *Misc. Respiratory Inhalants**-*Misc. Respiratory Inhalants*** sodium chloride inhalation nebulization solution 0.9 % P OTC *Dermatologicals* *Antibiotics - Topical**-*Antibiotic Mixtures Topical*** bacitracin-neomycin-polymyxin external ointment P OTC double antibiotic external ointment unit/gm P OTC triple antibiotic external ointment , P OTC *Antibiotics - Topical**-*Antibiotics - Topical*** bacitracin external ointment 500 unit/gm P OTC 6

10 bacitracin zinc external ointment 500 unit/gm P OTC *Antifungals - Topical**-*Antifungals - Topical*** terbinafine hcl external cream 1 % P OTC *Antifungals - Topical**-*Imidazole-Related Antifungals - Topical*** clotrimazole external solution 1 % P OTC *Antihistamines-Topical**-*Antihistamines - Topical*** allergy external cream 2 % P OTC anti-itch maximum strength external cream 2 % P OTC BENADRYL ITCH STOPPING EXTERNAL 2 % P OTC itch relief external cream 2 % P OTC *Corticosteroids - Topical**-*Corticosteroids - Topical*** AVEENO ANTI-ITCH MAX ST EXTERNAL CREAM 1 % P OTC hydrocortisone external cream 0.5 %, 1 % P OTC hydrocortisone external ointment 0.5 %, 1 % P OTC hydrocortisone max st external cream 1 % P OTC hydrocortisone max st/12 moist external cream 1 % P OTC HYDROSKIN EXTERNAL CREAM 1 % P OTC kp hydrocortisone external cream 1 % P OTC PREPARATION H HYDROCORTISONE EXTERNAL CREAM 1 % P OTC tgt anti-itch/aloe/vit e external cream 1 % P OTC *Corticosteroids - Topical**-*Topical Steroid Combinations*** hydrocortisone-aloe external cream 1 % P OTC sm hydrocortisone plus external cream 1 % P OTC *Scabicides & Pediculicides**-*Scabicides & Pediculicides*** permethrin external lotion 1 % P OTC; QL (60 ML per 31 days) *Gastrointestinal Agents - Misc.* *Antiflatulents**-*Antiflatulents*** mi-acid gas relief oral tablet chewable 80 mg P OTC mytab gas oral tablet chewable 80 mg P OTC simethicone oral suspension 40 mg/0.6ml P OTC simethicone oral tablet chewable 80 mg P OTC 7

11 *Genitourinary Agents - Miscellaneous* *Urinary Analgesics**-*Urinary Analgesics*** phenazopyridine hcl oral tablet 100 mg, 200 mg P *Hematopoietic Agents* *Cobalamins**-*Cobalamins*** cyanocobalamin injection solution 1000 mcg/ml P vitamin b-12 oral tablet 1000 mcg, 500 mcg P OTC vitamin b-12 sublingual tablet sublingual 1000 mcg P OTC vitamin b-12 er oral tablet extendedrelease* 1000 mcg P OTC *Folic Acid/Folates**-*Folic Acid/Folates*** folic acid oral tablet 1 mg P OTC *Iron**-*Iron*** ferro-bob oral tablet 325 (65 fe) mg P OTC ferrous sulfate oral elixir 220 (44 fe) mg/5ml P OTC ferrous sulfate oral tablet 325 (65 fe) mg P OTC ferrous sulfate oral tablet delayed release 324 (65 fe) mg, 325 (65 fe) mg P OTC ferrousul oral tablet 325 (65 fe) mg P OTC iron oral tablet 325 (65 fe) mg, 90 (18 fe) mg P OTC *Hypnotics* *Antihistamine Hypnotics**-*Antihistamine Hypnotic Combinations*** acetaminophen pm oral tablet mg P OTC; QL (62 EA per 31 Days) headache pm oral tablet mg P OTC; QL (62 EA per 31 days) mapap pm oral tablet mg P OTC; QL (62 EA per 31 days) pain relief pm extra strength oral tablet mg P OTC; QL (62 EA per 31 Days) pain reliever pm oral tablet mg P OTC; QL (62 EA per 31 days) *Antihistamine Hypnotics**-*Antihistamine Hypnotics*** compoz oral capsule 50 mg P OTC compoz oral tablet 50 mg P OTC NYTOL ORAL TABLET 25 MG P OTC SIMPLY SLEEP ORAL TABLET 25 MG P OTC sleep tabs oral tablet 25 mg P OTC sleep-tabs oral tablet 25 mg P OTC 8

12 SOMINEX ORAL TABLET 25 MG P OTC SOMINEX MAXIMUM STRENGTH ORAL TABLET 50 MG P OTC tetra-formula nighttime sleep oral tablet 50 mg P OTC *Laxatives* *Bulk Laxatives**-*Bulk Laxatives*** fiber oral tablet 625 mg P OTC fiber laxative oral tablet 625 mg P OTC fiber therapy oral powder 58.6 % P OTC fiber-lax oral tablet 625 mg P OTC FIBERGEN ORAL TABLET 625 MG P OTC KONSYL ORAL PACKET 100 % P OTC KONSYL FIBER ORAL TABLET 625 MG P OTC METAMUCIL ORAL POWDER 30.9 % P OTC METAMUCIL MULTIHEALTH FIBER ORAL POWDER 58.6 % P OTC METAMUCIL SMOOTH TEXTURE ORAL PACKET 28 % P OTC METAMUCIL SMOOTH TEXTURE ORAL POWDER 28.3 %, 58.6 % P OTC natural fiber therapy oral powder 30.9 %, % P OTC natural vegetable fiber oral powder % P OTC REGULOID ORAL CAPSULE 0.52 GM P OTC *Laxative Combinations**-*Laxatives & Dss*** DOC-Q-LAX ORAL TABLET MG P OTC PERI-COLACE ORAL TABLET MG P OTC senna plus oral tablet mg P OTC senna s oral tablet mg P OTC senna-docusate sodium oral tablet mg P OTC senna-s oral tablet mg P OTC senna-time s oral tablet mg P OTC SENNALAX-S ORAL TABLET MG P OTC sennosides-docusate sodium oral tablet mg P OTC *Laxatives - Miscellaneous**-*Laxatives - Miscellaneous*** sorbitol oral solution 70 % P OTC *Saline Laxatives**-*Saline Laxative Mixtures*** enema enema 7-19 gm/118ml P OTC 9

13 ra saline laxative oral solution gm/5ml P OTC *Saline Laxatives**-*Saline Laxatives*** citrate of magnesia oral solution gm/30ml P OTC CITROMA ORAL SOLUTION GM/30ML P OTC DULCOLAX MILK OF MAGNESIA ORAL SUSPENSION 400 MG/5ML P OTC magnesium citrate oral solution gm/30ml P OTC milk of magnesia oral suspension 400 mg/5ml, 7.75 % P OTC *Stimulant Laxatives**-*Stimulant Laxatives*** BISAC-EVAC ORAL TABLET DELAYED RELEASE 5 MG P OTC BISAC-EVAC SUPPOSITORY 10 MG P OTC biscolax suppository 10 mg P OTC CARTERS LITTLE PILLS ORAL TABLET DELAYED RELEASE 5 MG P OTC correct oral tablet delayed release 5 mg P OTC CORRECTOL ORAL TABLET DELAYED RELEASE 5 MG P OTC ducodyl oral tablet delayed release 5 mg P OTC EX-LAX ORAL TABLET CHEWABLE 15 MG P OTC EX-LAX ULTRA ORAL TABLET DELAYED RELEASE 5 MG P OTC FEENAMINT ORAL TABLET DELAYED RELEASE 5 MG P OTC FLEET LAXATIVE ORAL TABLET DELAYED RELEASE 5 MG P OTC gentle laxative oral tablet delayed release 5 mg P OTC laxative suppository 10 mg P OTC magic bullets suppository 10 mg P OTC natural senna laxative oral tablet mg P OTC senexon oral liquid 8.8 mg/5ml P OTC senexon oral tablet 8.6 mg P OTC senna oral syrup 8.8 mg/5ml P OTC senna oral tablet 15 mg, 8.6 mg P OTC senna lax oral tablet 8.6 mg P OTC senna laxative oral tablet 8.6 mg P OTC senna maximum strength oral tablet 25 mg P OTC SENNA SMOOTH ORAL TABLET 15 MG P OTC senna-lax oral tablet 8.6 mg P OTC senna-tabs oral tablet 8.6 mg P OTC 10

14 senna-time oral tablet 8.6 mg P OTC SENNACON ORAL TABLET 8.6 MG P OTC SENNO ORAL TABLET 8.6 MG P OTC stimulant laxative oral tablet delayed release 5 mg P OTC womens laxative oral tablet delayed release 5 mg P OTC *Surfactant Laxatives**-*Surfactant Laxatives*** CORRECTOL EXTRA GENTLE ORAL CAPSULE 100 MG P OTC d.o.s. oral capsule 250 mg P OTC diocto oral liquid 50 mg/5ml P OTC diocto oral syrup 60 mg/15ml P OTC docqlace oral capsule 100 mg P OTC docu soft oral capsule 100 mg P OTC docusate sodium oral tablet 100 mg P OTC DOCUSIL ORAL CAPSULE 100 MG P OTC dok oral capsule 100 mg, 250 mg P OTC dok oral tablet 100 mg P OTC dss oral capsule 100 mg, 250 mg P OTC DULCOLAX STOOL SOFTENER ORAL CAPSULE 100 MG P OTC kao-tin oral capsule 240 mg P OTC laxa basic oral capsule 100 mg, 250 mg P OTC silace oral liquid 150 mg/15ml P OTC silace oral syrup 60 mg/15ml P OTC SOF-LAX ORAL CAPSULE 100 MG P OTC stool softener oral capsule 100 mg, 250 mg P OTC stool softener laxative dc oral capsule 240 mg P OTC sur-q-lax oral capsule 240 mg P OTC SURFAK ORAL CAPSULE 240 MG P OTC *Medical Devices* *Respiratory Therapy Supplies**-*Respiratory Therapy Supplies*** ACE AEROSOL CLOUD ENHANCER P QL (2 EA per 365 days) IN-CHECK DIAL FLOW TRAINER DEVICE P QL (2 EA per 365 days) inhaler companions P OTC; QL (2 EA per 365 days) PFLEX P QL (2 EA per 365 days) 11

15 THRESHOLD IMT P QL (2 EA per 365 days) THRESHOLD PEP DEVICE P QL (2 EA per 365 days) WINDMILL TRAINER P QL (2 EA per 365 days) *Respiratory Therapy Supplies**-*Spacer/Aerosol-Holding Chambers & Supplies*** AEROCHAMBER MV P QL (2 EA per 365 days) AEROCHAMBER PLUS FLO-VU P QL (2 EA per 365 days) AEROCHAMBER PLUS FLO-VU LARGE P QL (2 EA per 365 days) AEROCHAMBER PLUS FLO-VU SMALL P QL (2 EA per 365 days) AEROCHAMBER PLUS FLO-VU W/MASK P QL (2 EA per 365 days) AEROCHAMBER W/FLOWSIGNAL P QL (2 EA per 365 days) AEROCHAMBER Z-STAT PLUS P QL (2 EA per 365 days) AEROCHAMBER Z-STAT PLUS CHAMBR P QL (2 EA per 365 days) EASIVENT P QL (2 EA per 365 days) MICROCHAMBER P QL (2 EA per 365 days) MICROSPACER P QL (2 EA per 365 days) OPTICHAMBER ADVANTAGE P QL (2 EA per 365 days) OPTIHALER P QL (2 EA per 365 days) OPTIHALER DEVICE P QL (2 EA per 365 days) POCKET CHAMBER DEVICE P QL (2 EA per 365 days) POCKET SPACER DEVICE P QL (2 EA per 365 days) WATCHHALER DEVICE P QL (2 EA per 365 days) *Minerals & Electrolytes* *Calcium**-*Calcium Combinations*** calcium oral tablet mg-unit P OTC calcium + d3 oral tablet mg-unit P OTC calcium 600-d oral tablet mg-unit P OTC calcium carbonate-vitamin d oral tablet mg-unit, mg-unit P OTC calcium high potency/vitamin d oral tablet mg-unit P OTC calcium-carb d oral tablet mg-unit P OTC calcium-vitamin d oral tablet mg-unit, mg-unit, mg-unit P OTC CALTRATE 600+D ORAL TABLET MG-UNIT P OTC 12

16 liquid calcium/vitamin d oral capsule mg-unit P OTC OYSCO 500+D ORAL TABLET MG-UNIT P OTC OYSCO D ORAL TABLET MG-UNIT P OTC oyst-cal d oral tablet mg-unit P OTC oyster calcium + d oral tablet mg-unit P OTC oyster shell calcium + d oral tablet mg-unit P OTC oyster shell calcium d oral tablet mg-unit P OTC oyster shell calcium/d oral tablet mg-unit, mg-unit P OTC oyster shell calcium/vitamin d oral tablet mg-unit P OTC oyster shell/vitamin d oral tablet mg-unit P OTC *Calcium**-*Calcium*** CAL-CARB FORTE ORAL TABLET 1250 MG P OTC calcarb 600 oral tablet 1500 mg P OTC CALCI-CHEW ORAL TABLET CHEWABLE 1250 MG P OTC calcium oral tablet 600 mg P OTC calcium 600 oral tablet 600 mg P OTC calcium carbonate oral suspension 1250 mg/5ml P OTC calcium carbonate oral tablet 1250 mg, 1500 mg, 600 mg P OTC calcium high potency oral tablet 600 mg P OTC calcium oyster shell oral tablet 1250 mg P OTC calcium-carb 600 oral tablet 600 mg P OTC CALTRATE 600 ORAL TABLET 1500 MG P OTC OYSCO 500 ORAL TABLET 500 MG P OTC OYSTERCAL ORAL TABLET 500 MG P OTC *Magnesium**-*Magnesium*** mag-delay oral tablet extendedrelease* 535 (64 mg) mg P OTC mag-sr oral tablet extendedrelease* 535 (64 mg) mg P OTC MAG-TAB SR ORAL TABLET EXTENDEDRELEASE* 84 MG (7MEQ) P OTC MAG64 ORAL TABLET EXTENDEDRELEASE* 535 (64 MG) MG P OTC magnacaps oral capsule 100 mg P OTC magnesium oral tablet 250 mg P OTC magnesium oxide oral tablet 400 (240 mg) mg P OTC MAGNESIUM-OXIDE ORAL TABLET 400 (241.3 MG) MG P OTC 13

17 *Zinc**-*Zinc*** ORAZINC ORAL CAPSULE 220 MG P OTC zinc sulfate oral capsule 220 mg P OTC zinc sulfate oral tablet 220 (50 zn) mg P OTC zinc-220 oral capsule 220 mg P OTC *Multivitamins* *B-Complex W/ Folic Acid**-*B-Complex W/ C & Folic Acid*** NEPHRONEX ORAL TABLET rena-vite rx oral tablet 1 mg RENAL ORAL CAPSULE 1 MG reno caps oral capsule 1 mg *Multiple Vitamins W/ Minerals**-*Multiple Vitamins W/ Minerals*** P P P P centamin oral liquid P OTC centavite oral liquid P OTC centavite a-z complete-mineral oral tablet P OTC CEROVITE ADVANCED FORMULA ORAL TABLET P OTC CERTAVITE/ANTIOXIDANTS ORAL LIQUID P OTC formula twenty-one oral tablet P OTC gerivite complete oral tablet P OTC golden age vitamin/minerals oral liquid P OTC multivitamin & mineral oral liquid P OTC SUPER NU-THERA ORAL TABLET P OTC thera vital m oral tablet P OTC therabasic-m oral tablet P OTC therapeutic liquid oral solution P OTC therapeutic-m oral tablet P OTC TOTAL FORMULA 3 ORAL TABLET P OTC *Multivitamins**-*Multivitamins*** daily multiple vitamins oral tablet P OTC daily vite oral tablet P OTC daily vites oral tablet P OTC multi-day oral tablet P OTC multi-vitamin oral tablet P OTC 14

18 multi-vitamins oral tablet P OTC once daily oral tablet P OTC one-daily multi vitamins oral tablet P OTC THERA ORAL TABLET P OTC thera-tabs oral tablet P OTC THERA/BETA-CAROTENE ORAL TABLET P OTC therapeutic oral tablet P OTC *Ped Mv W/ Fluoride**-*Ped Mv W/ Fluoride*** multi-vit/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml multi-vitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg multivitamins/fluoride oral tablet chewable 0.25 mg *Specialty Vitamins Products**-*Specialty Vitamins Products*** P P P P vitamins for hair oral tablet P OTC *Nasal Agents - Systemic And Topical* *Nasal Agents - Misc.**-*Nasal Agents - Misc.*** altamist spray nasal solution 0.65 % P OTC AYR NASAL SOLUTION 0.65 % P OTC deep sea nasal spray nasal solution 0.65 % P OTC HUMIST NASAL SOLUTION 0.65 % P OTC LITTLE NOSES SALINE NASAL SOLUTION 0.65 % P OTC na-zone nasal solution 0.65 % P OTC NASAL MOIST NASAL SOLUTION 0.65 % P OTC OCEAN FOR KIDS NASAL SOLUTION 0.65 % P OTC saline mist spray nasal solution 0.65 % P OTC saline nasal spray nasal solution 0.65 % P OTC sea soft nasal mist nasal solution 0.65 % P OTC *Nasal Antiallergy**-*Nasal Mast Cell Stabilizers*** cromolyn sodium nasal aerosol, solution 5.2 mg/act P OTC *Sympathomimetic Decongestants**-*Systemic Decongestants*** pseudoephedrine hcl oral tablet 30 mg, 60 mg P OTC 15

19 *Ophthalmic Agents* *Artificial Tears And Lubricants**-*Artificial Tear And Lubricant Combinations*** artificial tears ophthalmic ointment % P OTC HYPOTEARS OPHTHALMIC SOLUTION 1-1 % P OTC *Artificial Tears And Lubricants**-*Artificial Tear Ointments*** tears again ophthalmic ointment P OTC ULTRA FRESH PM OPHTHALMIC OINTMENT P OTC *Artificial Tears And Lubricants**-*Artificial Tear Solutions*** tears again ophthalmic solution P OTC *Artificial Tears And Lubricants**-*Artificial Tears And Lubricants*** artificial tears ophthalmic solution 1.4 % P OTC; QL (15 ML per 31 days) liquitears ophthalmic solution 1.4 % P OTC; QL (15 ML per 31 Days) polyvinyl alcohol ophthalmic solution 1.4 % P OTC; QL (15 ML per 31 Days) *Ophthalmics - Misc.**-*Ophthalmic Antiallergic*** ALAWAY OPHTHALMIC SOLUTION % P OTC ketotifen fumarate ophthalmic solution % P OTC *Otic Agents* *Otic Agents - Miscellaneous**-*Otic Agents - Miscellaneous*** auraphene-b otic solution 6.5 % P OTC AURO EARDROPS OTIC SOLUTION 6.5 % P OTC E-R-O EAR DROPS OTIC SOLUTION 6.5 % P OTC E-R-O EAR WAX REMOVAL SYSTEM OTIC SOLUTION 6.5 % P OTC ear drops earwax aid otic solution 6.5 % P OTC earwax treatment drops otic solution 6.5 % P OTC MURINE EAR OTIC SOLUTION 6.5 % P OTC MURINE EAR WAX REMOVAL SYSTEM OTIC SOLUTION 6.5 % P OTC OTIX OTIC SOLUTION 6.5 % P OTC thera-ear otic solution 6.5 % P OTC *Psychotherapeutic And Neurological Agents - Misc.* *Smoking Deterrents**-*Smoking Deterrents*** 16

20 nicotine transdermal patch 24 hr 14 mg/24hr, 21 mg/24hr, 7 mg/24hr P OTC; QL (70 EA per 365 days) nicotine polacrilex mouth/throat gum 2 mg, 4 mg P OTC; QL (2016 EA per 365 days) *Ulcer Drugs* *Proton Pump Inhibitors**-*Proton Pump Inhibitors*** omeprazole oral tablet delayed release 20 mg P OTC *Vaginal Products* *Vaginal Anti-Infectives**-*Imidazole-Related Antifungals*** miconazole nitrate vaginal cream 2 % P OTC *Vitamins* *Oil Soluble Vitamins**-*Vitamin D*** CALCIFEROL ORAL SOLUTION 8000 UNIT/ML P OTC vitamin d oral tablet 400 unit P OTC vitamin d (ergocalciferol) oral capsule unit P QL (4 EA per 28 Days) vitamin d-400 oral tablet 400 unit P OTC vitamin d3 oral capsule 2000 unit P OTC vitamin d3 oral tablet 1000 unit, 400 unit P OTC *Oil Soluble Vitamins**-*Vitamin K*** vitamin k (phytonadione) oral tablet 100 mcg P OTC *Water Soluble Vitamins**-*Vitamin C*** ascorbic acid oral tablet 1000 mg, 250 mg, 500 mg P OTC ascorbic acid oral tablet chewable 250 mg P OTC c-500 oral tablet chewable 500 mg P OTC vitamin c oral syrup 500 mg/5ml P OTC vitamin c oral tablet 100 mg, 1000 mg, 250 mg, 500 mg P OTC vitamin c oral tablet chewable 100 mg, 250 mg P OTC 17

21 18

22 Index of Drugs ACE AEROSOL CLOUD ENHANCER acetaminophen... 1 acetaminophen pm... 8 ACID GONE... 3 AEROCHAMBER MV AEROCHAMBER PLUS FLO-VU AEROCHAMBER PLUS FLO-VU LARGE AEROCHAMBER PLUS FLO-VU SMALL AEROCHAMBER PLUS FLO-VU W/MASK AEROCHAMBER W/FLOWSIGNAL AEROCHAMBER Z-STAT PLUS AEROCHAMBER Z-STAT PLUS CHAMBR alamag plus... 2 ALAWAY alcalak... 3 aler-cap... 5 aler-dryl... 5 alertab... 5 aller-chlor... 4 allergy... 4, 7 allergy relief... 5 allergy relief childrens... 5 ALMACONE... 2 altamist spray altaryl... 5 aluminum hydroxide gel... 3 antacid... 2, 3 antacid anti-gas... 2 antacid anti-gas max strength... 2 antacid extra strength... 2 antacid i... 2 antacid iii... 2 anti-diarrheal... 4 anti-hist... 5 anti-hist allergy... 5 anti-itch maximum strength... 7 apap... 1 apap extra strength... 1 artificial tears ascorbic acid aspirin... 2 aspirin adult low strength... 2 aspirin childrens... 2 aspirin ec... 2 aspirin ec low dose... 2 aspirin low dose... 2 auraphene-b AURO EARDROPS AVEENO ANTI-ITCH MAX ST... 7 AYR bacitracin... 6 bacitracin zinc... 7 bacitracin-neomycin-polymyxin... 6 BANOPHEN... 5 BD GLUCOSE... 3 BENADRYL ALLERGY CHILDRENS... 5 BENADRYL ITCH STOPPING... 7 BISAC-EVAC biscolax bismatrol... 4 bismuth... 4 BROTAPP... 6 c calcarb CAL-CARB FORTE CALCI-CHEW CALCIFEROL calcium... 12, 13 calcium + d calcium calcium 600-d calcium antacid... 3 calcium antacid extra strength... 3 calcium carbonate calcium carbonate antacid... 3 calcium carbonate-vitamin d calcium high potency calcium high potency/vitamin d calcium oyster shell calcium-carb calcium-carb d calcium-vitamin d CAL-GEST ANTACID... 3 CALTRATE CALTRATE 600+D CARTERS LITTLE PILLS centamin centavite centavite a-z complete-mineral CEROVITE ADVANCED FORMULA CERTAVITE/ANTIOXIDANTS cetirizine hcl... 6 cetirizine hcl childrens... 6 cetirizine hcl childrens alrgy... 6 childrens non-asa pain relief... 1 childrens non-aspirin... 1 childrens non-aspirin pain... 1 childrens pain reliever... 1 childrens silapap... 1 childrens tactinal... 1 chlorhist... 5 chlorphen... 5 citrate of magnesia CITROMA clotrimazole... 7 complete allergy medication... 5 complete allergy relief... 5 compoz... 8 correct CORRECTOL CORRECTOL EXTRA GENTLE cromolyn sodium cyanocobalamin... 8 d.o.s

23 daily multiple vitamins daily vite daily vites deep sea nasal spray DIABETIC TUSSIN ALLERGY... 5 diocto diotame... 4 diphenhist... 5 diphenhydramine hcl... 5 docqlace DOC-Q-LAX... 9 docu soft docusate sodium DOCUSIL dok DORMIN... 5 double antibiotic... 6 dss ducodyl DULCOLAX MILK OF MAGNESIA DULCOLAX STOOL SOFTENER ear drops earwax aid earwax treatment drops EASIVENT ECPIRIN... 2 ed-apap... 1 enema... 9 E-R-O EAR DROPS E-R-O EAR WAX REMOVAL SYSTEM EX-LAX EX-LAX ULTRA FEENAMINT ferro-bob... 8 ferrous sulfate... 8 ferrousul... 8 fiber... 9 fiber laxative... 9 fiber therapy... 9 FIBERGEN... 9 fiber-lax... 9 FLEET LAXATIVE folic acid... 8 formula twenty-one genahist... 5 gentle laxative geri-lanta... 2 gerivite complete glucose... 3 golden age vitamin/minerals headache pm... 8 HUMIST hydrocortisone... 7 hydrocortisone max st... 7 hydrocortisone max st/12 moist... 7 hydrocortisone-aloe... 7 HYDROSKIN... 7 HYPOTEARS ibuprofen... 1 IN-CHECK DIAL FLOW TRAINER inhaler companions ipecac... 4 iron... 8 itch relief... 7 KAOPECTATE... 4 KAOPECTATE EXTRA STRENGTH... 4 kao-tin... 4, 11 ketotifen fumarate KONSYL... 9 KONSYL FIBER... 9 kp hydrocortisone... 7 laxa basic laxative liquid calcium/vitamin d liquitears LITTLE NOSES SALINE LOPERAMIDE A-D... 4 loperamide hcl... 4 loratadine... 6 loratadine hives relief... 6 MAALOX... 3 MAALOX ADVANCED... 2 MAALOX ADVANCED MAX ST... 3 MAALOX MAX... 3 MAALOX MULTI SYMPTOM MAX ST MAALOX REGULAR STRENGTH... 3 MAG mag-delay magic bullets magnacaps magnesium magnesium citrate magnesium oxide... 3, 13 MAGNESIUM-OXIDE mag-sr MAG-TAB SR mapap... 1 mapap arthritis pain... 1 mapap pm... 8 maxapap maximum strength... 1 maxapap regular strength... 1 meclizine hcl... 4 melatonin maximum strength... 1 METAMUCIL... 9 METAMUCIL MULTIHEALTH FIBER... 9 METAMUCIL SMOOTH TEXTURE... 9 MI-ACID... 3 mi-acid gas relief... 7 miconazole nitrate MICROCHAMBER MICROSPACER milantex... 3 milantex extra strength... 3 milk of magnesia MINTOX PLUS... 3 mucus relief... 6 multi-day multi-vit/fluoride multi-vitamin multivitamin & mineral multivitamin/fluoride multi-vitamin/fluoride multi-vitamins... 15

24 multivitamins/fluoride MURINE EAR MURINE EAR WAX REMOVAL SYSTEM mytab gas... 7 NASAL MOIST natural fiber therapy... 9 natural senna laxative natural vegetable fiber... 9 na-zone NEPHRONEX nicotine nicotine polacrilex non-aspirin... 1 non-aspirin extra strength... 1 non-aspirin pain relief... 1 nortemp infants... 2 NYTOL... 8 OCEAN FOR KIDS omeprazole once daily one-daily multi vitamins OPERAND POVIDONE-IODINE... 6 OPTICHAMBER ADVANTAGE OPTIHALER ORAZINC OTIX OYSCO OYSCO 500+D OYSCO D oyst-cal d oyster calcium + d oyster shell calcium + d oyster shell calcium d oyster shell calcium/d oyster shell calcium/vitamin d oyster shell/vitamin d OYSTERCAL pain & fever childrens... 2 pain relief... 2 pain relief extra strength... 2 pain relief pm extra strength... 8 pain reliever pm... 8 PERI-COLACE... 9 permethrin... 7 PFLEX pharbedryl... 5 PHARBETOL... 2 PHARBETOL EXTRA STRENGTH... 2 phenazopyridine hcl... 8 pink bismuth... 4 POCKET CHAMBER POCKET SPACER polyvinyl alcohol povidone-iodine... 6 PREPARATION H HYDROCORTISONE... 7 pseudoephedrine hcl q-dryl... 5 q-pap... 2 Q-TAPP... 6 quenalin... 5 ra saline laxative refenesen... 6 refenesen REGULOID... 9 RENAL rena-vite rx reno caps robafen... 6 saline mist spray saline nasal spray SCOT-TUSSIN ALLERGY RELIEF... 5 sea soft nasal mist senexon senna senna lax senna laxative senna maximum strength senna plus... 9 senna s... 9 SENNA SMOOTH SENNACON senna-docusate sodium... 9 senna-lax SENNALAX-S... 9 senna-s... 9 senna-tabs senna-time senna-time s... 9 SENNO sennosides-docusate sodium... 9 silace siladryl allergy... 5 silphen cough... 5 simethicone... 7 SIMPLY ALLERGY... 6 SIMPLY SLEEP... 8 sleep tabs... 8 sleep-tabs... 8 sm hydrocortisone plus... 7 sodium bicarbonate... 3 sodium chloride... 6 SOF-LAX SOMINEX... 9 SOMINEX MAXIMUM STRENGTH... 9 sorbitol... 9 stimulant laxative stomach relief... 4 stomach relief plus... 4 stool softener stool softener laxative dc SUPER NU-THERA SURFAK sur-q-lax tactinal... 2 tactinal extra strength... 2 tears again terbinafine hcl... 7 tetra-formula nighttime sleep... 9 tgt anti-itch/aloe/vit e... 7 THERA thera vital m THERA/BETA-CAROTENE... 15

25 therabasic-m thera-ear therapeutic therapeutic liquid therapeutic-m thera-tabs THRESHOLD IMT THRESHOLD PEP TITRALAC... 3 total allergy... 6 TOTAL ALLERGY MEDICINE... 6 TOTAL FORMULA tri-buffered aspirin... 2 triple antibiotic... 6 ultilet glucose... 4 ULTRA FRESH PM vitamin b vitamin b-12 er... 8 vitamin c vitamin d vitamin d (ergocalciferol) vitamin d vitamin d vitamin k (phytonadione) vitamins for hair WATCHHALER WINDMILL TRAINER womens laxative zinc sulfate zinc

26 This information is available for free in other languages. Please call our Customer Service number at , Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives are available Monday Sunday, 8 a.m. to 8 p.m. TTY users should call Esta información está disponible gratis en otros idiomas. Por favor llame a nuestro número de Servicio al Cliente al , de lunes a viernes, de 8 a.m. a 8 p.m. Entre el 1 de octubre y el 14 de febrero, los representantes están disponibles de lunes a domingo de 8 a.m. a 8 p.m. Los usuarios de TTY deben llamar al WellCare (HMO SNP) is a Medicare Advantage organization with a Medicare contract and a contract with the Florida Medicaid program. Enrollment in WellCare Florida Liberty (HMO SNP) depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, co-payments and restrictions may apply. Benefits, premium and/or co-payments/coinsurance may change on January 1 of each year. Please contact WellCare for details. P.O. Box Tampa, FL

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